AIDS and Behavior

, Volume 24, Issue 1, pp 151–164 | Cite as

The Relationship Between Discrimination and Missed HIV Care Appointments Among Women Living with HIV

  • Andrew E. Cressman
  • Chanelle J. HoweEmail author
  • Amy S. Nunn
  • Adaora A. Adimora
  • David R. Williams
  • Mirjam-Colette Kempf
  • Aruna Chandran
  • Eryka L. Wentz
  • Oni J. Blackstock
  • Seble G. Kassaye
  • Jennifer Cohen
  • Mardge H. Cohen
  • Gina M. Wingood
  • Lisa R. Metsch
  • Tracey E. Wilson
Original Paper


Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women’s Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.


HIV Social discrimination Outpatient care Women Health status disparities 



Data in this manuscript were collected by the Women’s Interagency HIV Study (WIHS). The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). WIHS (Principal Investigators): UAB-MS WIHS (Mirjam-Colette Kempf and Deborah Konkle-Parker), U01-AI-103401; Atlanta WIHS (Ighovwerha Ofotokun and Gina Wingood), U01-AI-103408; Bronx WIHS (Kathryn Anastos and Anjali Sharma), U01-AI-035004; Brooklyn WIHS (Howard Minkoff and Deborah Gustafson), U01-AI-031834; Chicago WIHS (Mardge Cohen and Audrey French), U01-AI-034993; Metropolitan Washington WIHS (Seble Kassaye), U01-AI-034994; Miami WIHS (Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (Adaora Adimora), U01-AI-103390; Connie Wofsy Women’s HIV Study, Northern California (Ruth Greenblatt, Bradley Aouizerat, and Phyllis Tien), U01-AI-034989; WIHS Data Management and Analysis Center (Stephen Gange and Elizabeth Golub), U01-AI-042590; Southern California WIHS (Joel Milam), U01-HD-032632 (WIHS I—WIHS IV). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women’s Health. WIHS data collection is also supported by UL1-TR000004 (UCSF CTSA), UL1-TR000454 (Atlanta CTSA), P30-AI-050410 (UNC CFAR), and P30-AI-027767 (UAB CFAR).


This study was funded by the National Institutes of Health Grants U01-AI-103401, U01-AI-103408, U01-AI-035004, U01-AI-031834, U01-AI-034993, U01-AI-034994, U01-AI-103397, U01-AI-103390, U01-AI-034989, U01-AI-042590, U01-HD-032632, UL1-TR000004, UL1-TR000454, P30-AI-050410, and P30-AI-027767.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10461_2019_2522_MOESM1_ESM.docx (119 kb)
Supplementary material 1 (DOCX 118 kb)


  1. 1.
    Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793–800.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Giordano TP, White AC Jr, Sajja P, Graviss EA, Arduino RC, Adu-Oppong A, et al. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndrom (1999). 2003;32(4):399–405.Google Scholar
  3. 3.
    Mugavero MJ, Lin HY, Allison JJ, Giordano TP, Willig JH, Raper JL, et al. Racial disparities in HIV virologic failure: do missed visits matter? J Acquir Immune Defic Syndrom (1999). 2009;50(1):100–8.Google Scholar
  4. 4.
    Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009;48(2):248–56.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Horberg MA, Hurley LB, Silverberg MJ, Klein DB, Quesenberry CP, Mugavero MJ. Missed office visits and risk of mortality among HIV-infected subjects in a large healthcare system in the United States. AIDS Patient Care STDs. 2013;27(8):442–9.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, et al. Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis. 2014;59(10):1471–9.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Howe CJ, Napravnik S, Cole SR, Kaufman JS, Adimora AA, Elston B, et al. African American race and HIV virological suppression: beyond disparities in clinic attendance. Am J Epidemiol. 2014;179(12):1484–92.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Cohen JK, Santos G-M, Moss NJ, Coffin PO, Block N, Klausner JD. Regular clinic attendance in two large San Francisco HIV primary care settings. Aids Care-Psychol Soc-Med Asp Aids/Hiv. 2016;28(5):579–84.Google Scholar
  9. 9.
    Mugavero MJ, Lin HY, Allison JJ, Willig JH, Chang PW, Marler M, et al. Failure to establish HIV care: characterizing the “no show” phenomenon. Clin Infect Dis. 2007;45(1):127–30.PubMedGoogle Scholar
  10. 10.
    Kang SY, Goldstein MF, Deren S. Gender differences in health status and care among HIV-infected minority drug users. AIDS Care. 2008;20(9):1146–51.PubMedGoogle Scholar
  11. 11.
    Rothman RE, Kelen GD, Harvey L, Shahan JB, Hairston H, Burah A, et al. Factors associated with no or delayed linkage to care in newly diagnosed human immunodeficiency virus (HIV)-1-infected patients identified by emergency department-based rapid HIV screening programs in two urban EDs. Acad Emerg Med. 2012;19(5):497–503.PubMedGoogle Scholar
  12. 12.
    Meyer JP, Zelenev A, Wickersham JA, Williams CT, Teixeira PA, Altice FL. Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study. Am J Public Health. 2014;104(3):434–41.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Sohler NL, Li X, Cunningham CO. Gender disparities in HIV health care utilization among the severely disadvantaged: can we determine the reasons? AIDS Patient Care STDs. 2009;23(9):775–83.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Aziz M, Smith KY. Challenges and successes in linking HIV-infected women to care in the United States. Clin Infect Dis. 2011;52(Suppl 2):S231–7.PubMedGoogle Scholar
  15. 15.
    Jary David, Jary Julia. Collins Dictionary of Sociology. 4th ed. London: Collins; 2006.Google Scholar
  16. 16.
    Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32(1):20–47.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Lewis TT, Cogburn CD, Williams DR. Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. Annu Rev Clin Psychol. 2015;11:407–40.PubMedPubMedCentralGoogle Scholar
  18. 18.
    Seeman TE, Crimmins E, Huang MH, Singer B, Bucur A, Gruenewald T, et al. Cumulative biological risk and socio-economic differences in mortality: MacArthur studies of successful aging. Soc Sci Med. 2004;58(10):1985–97.PubMedGoogle Scholar
  19. 19.
    Djuric Z, Bird CE, Furumoto-Dawson A, Rauscher GH, Ruffin MT, Stowe RP, et al. Biomarkers of psychological stress in health disparities research. Open Biomark J. 2008;1:7–19.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health. 2008;98(9 Suppl):S29–37.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Britt-Spells AM, Slebodnik M, Sands LP, Rollock D. Effects of perceived discrimination on depressive symptoms among black men residing in the united states: a meta-analysis. Am J Men’s Health. 2018;12(1):52–63.Google Scholar
  22. 22.
    Yehia BR, Stewart L, Momplaisir F, Mody A, Holtzman CW, Jacobs LM, et al. Barriers and facilitators to patient retention in HIV care. BMC Infect Dis. 2015;15:246.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Zuniga JA, Yoo-Jeong M, Dai T, Guo Y, Waldrop-Valverde D. The role of depression in retention in care for persons living with HIV. AIDS Patient Care STDs. 2016;30(1):34–8.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Pence BW, Mills JC, Bengtson AM, Gaynes BN, Breger TL, Cook RL, et al. Association of increased chronicity of depression with hiv appointment attendance, treatment failure, and mortality among HIV-infected adults in the United States. JAMA Psychiatry. 2018;75(4):379–85.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531–54.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2010–2015. Atlanta: Centers for Disease Control and Prevention; 2018.Google Scholar
  27. 27.
    Wingood GM, Diclemente RJ, Mikhail I, McCree DH, Davies SL, Hardin JW, et al. HIV discrimination and the health of women living with HIV. Women Health. 2007;46(2–3):99–112.PubMedGoogle Scholar
  28. 28.
    Turan B, Rogers AJ, Rice WS, Atkins GC, Cohen MH, Wilson TE, et al. Association between perceived discrimination in healthcare settings and HIV medication adherence: mediating psychosocial mechanisms. AIDS Behav. 2017;21(12):3431–9.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Bogart LM, Wagner GJ, Galvan FH, Klein DJ. Longitudinal relationships between antiretroviral treatment adherence and discrimination due to HIV-serostatus, race, and sexual orientation among African-American men with HIV. Ann Behav Med. 2010;40(2):184–90.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Barkan SE, Melnick SL, Preston-Martin S, Weber K, Kalish LA, Miotti P, et al. The women’s interagency HIV study. WIHS Collaborative Study Group. Epidemiology. 1998;9(2):117–25.PubMedGoogle Scholar
  31. 31.
    Bacon MC, von Wyl V, Alden C, Sharp G, Robison E, Hessol N, et al. The Women’s Interagency HIV Study: an observational cohort brings clinical sciences to the bench. Clin Diagn Lab Immunol. 2005;12(9):1013–9.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Adimora AA, Ramirez C, Benning L, Greenblatt RM, Kempf M-C, Tien PC, et al. Cohort profile: the women’s interagency HIV study (WIHS). Int J Epidemiol. 2018;47(2):393–400.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Williams DR. Race, socioeconomic status, and health. The added effects of racism and discrimination. Ann N Y Acad Sci. 1999;896:173–88.PubMedGoogle Scholar
  34. 34.
    Gilbert PA, Zemore SE. Discrimination and drinking: a systematic review of the evidence. Soc Sci Med (1982). 1982;2016(161):178–94.Google Scholar
  35. 35.
    Hunte HE, Barry AE. Perceived discrimination and DSM-IV-based alcohol and illicit drug use disorders. Am J Public Health. 2012;102(12):e111–7.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Gee GC, Delva J, Takeuchi DT. Relationships between self-reported unfair treatment and prescription medication use, illicit drug use, and alcohol dependence among Filipino Americans. Am J Public Health. 2007;97(5):933–40.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Williams DR. Measuring Discrimination Resource 2016 [Available from:
  38. 38.
    Williams DR, Yan Y, Jackson JS, Anderson NB. Racial differences in physical and mental health: socio-economic status, stress and discrimination. J Health Psychol. 1997;2(3):335–51.PubMedGoogle Scholar
  39. 39.
    Kessler RC, Mickelson KD, Williams DR. The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. J Health Soc Behav. 1999;40(3):208–30.PubMedGoogle Scholar
  40. 40.
    Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.Google Scholar
  41. 41.
    Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.Google Scholar
  42. 42.
    Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging. 1997;12(2):277–87.PubMedGoogle Scholar
  43. 43.
    US Department of Health and Human Services U.S. Department of Agriculture. 2015–2020Dietary guidelines for Americans. Washington: US Department of Health and Human Services U.S. Department of Agriculture; 2015.Google Scholar
  44. 44.
    Wacholder S. Binomial regression in GLIM: estimating risk ratios and risk differences. Am J Epidemiol. 1986;123(1):174–84.PubMedGoogle Scholar
  45. 45.
    Howe CJ, Cole SR, Westreich DJ, Greenland S, Napravnik S, Eron JJ Jr. Splines for trend analysis and continuous confounder control. Epidemiology (Cambridge, Mass). 2011;22(6):874–5.PubMedCentralGoogle Scholar
  46. 46.
    Robins JM, Hernan MA, Brumback B. Marginal structural models and causal inference in epidemiology. Epidemiology (Cambridge, Mass). 2000;11(5):550–60.Google Scholar
  47. 47.
    VanderWeele TJ. Marginal structural models for the estimation of direct and indirect effects. Epidemiology (Cambridge, Mass). 2009;20(1):18–26.Google Scholar
  48. 48.
    Hernan MA, Robins JM. Causal inference. Boca Raton: Chapman & Hall/CRC; 2019.Google Scholar
  49. 49.
    Cole SR, Hernan MA. Constructing inverse probability weights for marginal structural models. Am J Epidemiol. 2008;168(6):656–64.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Wilson TE, Kay ES, Turan B, Johnson MO, Kempf M-C, Turan JM, et al. Healthcare empowerment and HIV viral control: mediating roles of adherence and retention in care. Am J Prev Med. 2018;54(6):756–64.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Krieger N, Williams DR, Moss NE. Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health. 1997;18:341–78.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Andrew E. Cressman
    • 1
  • Chanelle J. Howe
    • 1
    Email author
  • Amy S. Nunn
    • 2
  • Adaora A. Adimora
    • 3
  • David R. Williams
    • 4
    • 5
  • Mirjam-Colette Kempf
    • 6
  • Aruna Chandran
    • 7
  • Eryka L. Wentz
    • 7
  • Oni J. Blackstock
    • 8
  • Seble G. Kassaye
    • 9
  • Jennifer Cohen
    • 10
  • Mardge H. Cohen
    • 11
  • Gina M. Wingood
    • 12
    • 13
  • Lisa R. Metsch
    • 12
  • Tracey E. Wilson
    • 14
  1. 1.Department of Epidemiology, Centers for Epidemiology and Environmental HealthBrown University School of Public HealthProvidenceUSA
  2. 2.Department of Behavioral and Social Sciences, Center for Health Equity ResearchBrown University School of Public HealthProvidenceUSA
  3. 3.School of Medicine and UNC Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapelhillUSA
  4. 4.Department of Social and Behavioral SciencesHarvard T.H. Chan School of Public HealthBostonUSA
  5. 5.Department of African and African American StudiesHarvard UniversityCambridgeUSA
  6. 6.Schools of Nursing, Public Health, MedicineUniversity of Alabama at BirminghamBirminghamUSA
  7. 7.Department of Epidemiology, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA
  8. 8.Montefiore and Albert Einstein College of MedicineBronxUSA
  9. 9.Department of MedicineGeorgetown UniversityWashingtonUSA
  10. 10.Department of Clinical PharmacyUniversity of CaliforniaSan FranciscoUSA
  11. 11.Departments of MedicineStroger Hospital and Rush UniversityChicagoUSA
  12. 12.Department of Sociomedical Sciences, Mailman School of Public HealthColumbia UniversityNew YorkUSA
  13. 13.Lerner Center for Public Health Promotion, Mailman School of Public HealthColumbia UniversityNew YorkUSA
  14. 14.Department of Community Health Sciences, School of Public HealthState University of New York Downstate Medical CenterBrooklynUSA

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